Provider Demographics
NPI:1629306667
Name:DITOMASSO, MICHAEL JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:DITOMASSO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13834 SW 122ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6052
Mailing Address - Country:US
Mailing Address - Phone:305-256-4324
Mailing Address - Fax:305-256-5610
Practice Address - Street 1:13834 SW 122ND CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6052
Practice Address - Country:US
Practice Address - Phone:305-256-4324
Practice Address - Fax:305-256-5610
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY-5449103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7672951 00Medicaid